Overview
Mrs C complained that there had been a significant delay in diagnosing her late husband (Mr C)'s kidney condition and, further, that he had not been told he was suffering from kidney problems for some months. Mr C had been treated as an emergency by Crosshouse Hospital in February 2005. He was then investigated over several months as an out-patient at a urology clinic and admitted as an in-patient to Ayr Hospital (Hospital 2) on 19 January 2006 and, sadly, died there on 30 January 2006. Mrs C had concerns about the treatment provided to Mr C during this period of admission. She said she believed that his medication was withdrawn prior to this death and that, during the weekend prior to his death, a nursing care plan was not followed. Mrs C said that during this period of admission Mr C was not treated with appropriate dignity and respect and, in particular, he had died unobserved and been found by a cleaner on 30 January 2006.
Specific complaints and conclusions
The complaints which have been investigated are that:
(a) there was a delay in diagnosing Mr C's kidney condition and his treatment for this was inadequate (upheld);
(b) information about Mr C's kidney condition was not appropriately communicated to him (upheld);
(c) medication was withdrawn inappropriately during the last few days of Mr C's life (not upheld);
(d) nursing care was inadequate and, in particular, the care plan not adhered to over the last few days of Mr C's life (upheld); and
(e) Mr C was not treated with appropriate dignity and respect while in Hospital 2 (no finding).
Redress and recommendations
The Ombudsman recommends that the Board:
(i) apologise to Mrs C for the delays identified in diagnosing Mr C's condition and, as a result, failing to inform him that he was suffering from severe impairment of kidney function following the ultrasound taken in June 2005;
(ii) ensure that the clinical team involved in Mr C's care consider the lessons to be learned as a result of the failings identified in this report;
(iii) review a random sample of the results of ultrasounds taken, to ensure that they are being followed up appropriately;
(iv) review their procedures for arranging urgent IVPs, to ensure that the delay identified in this case is prevented in the future where possible;
(v) undertake a short, focussed audit of letters issued by the Urological Unit to GPs and provide evidence of the results and any action flowing from this;
(vi) the Consultant should share this case with his appraiser at annual appraisal if this has not already been done;
(vii) use this complaint as a case study with complaints handling staff, to demonstrate the importance of answering clearly the concerns raised with appropriate information;
(viii) apologise to Mrs C for the failure to provide an acceptable standard of nursing care to Mr C during the weekend of 28 to 30 January 2006;
(ix) undertake a selective audit of nursing records for this ward for weekends and provide her with a copy of the results;
(x) apologise to Mrs C for the failures in record keeping; and
(xi) ask the Consultant to reflect on how his approach may be perceived.